Ohio First Episode Psychosis (FEP) Program Participant
Consent for Interviews and Surveys (Parental Consent)
What am I being asked to do? As part of your child’s participation in Ohio’s First Episode Psychosis (FEP) Program, the Bureau of Research andEvaluation at the Ohio Department of Mental Health and Addiction Services (OhioMHAS) is asking you to participate in several surveys. There are no right or wrong answers on the surveys, we just need your honest opinions about the care that is being provided.
Will I be compensated for my participation?There is no remuneration for participation in the evaluation.
What is the purpose of the surveys? The information provided from these surveys will 1) assist us in improving the care and services provided to your child.2) Help the FEP program collect the data required by our funder, the Substance Abuse and Mental Health Services Administration (SAMHSA) for the Government Performance and Results Act (GPRA) required for this grant. Questions will ask about your child’s involvement in the Treatment project, the services they may be receiving, their quality of life, level of functioning, and other potentially sensitive questions.
How long will the surveys take? Surveys will be conducted individually and should take anywhere from 45 minutes to an hour. Most interviews will occur in person; where necessary phone interviews may occur.
Who is doing the surveys?The interviews will be administered by staff at your local provider agency. They have been trained in administering the surveys we are collecting and will be understanding and helpful should any difficulties occur. Once the information is collected, it will be stored in a secure database where only local provider agency staff and OhioMHAS researchers can access it.
Do I have to participate? While your child has agreed to participate in treatmentservices,his or her participation in the evaluation is voluntary. However, we really want to hear what he or she has to say. If he or she is uncomfortable with any questions your he or she can decline to respond or stop at any time. There is no penalty for stopping or not participating; your child’streatment or services will not be affected in any way.
Who will know what I share and how do we protect your privacy? Only your child’s clinician and research staff trained in confidentiality protection will be allowed access to the responses. Even upon request, we cannot turn over the responses to the supervisor, or parent/guardian. We will combine the responses from all survey participants to determine the effectiveness of the services your child received. Reports will be provided to the local provider agencies and the funder containing the responses, but the information will be de-identified. No one will know which answers are your child’s because answers will be combined and no names will be used.
Will participating help or hurt me? Many people like sharing their experiences and opinions. The questions on the surveys focus on your child’s mental health symptoms, functioning, and quality of life and progress towards treatment goals.Sometimes individuals choose to share personal experiences that can be stressful or emotional. If that happens your child may talk with clinician about those feelings. However, we are required by law to report if your child report has been harmed or is intending to harm someone else.
Who can I call if I have questions? You can call the Office of Quality, Planning, and Research at ODMH (614-466-8651) and ask to speak with Kraig Knudsen; or you can e-mail him: .
Agreement: I agree to have my child participate in interviews and surveys for First Episode Psychosis program. I understand that theirinput is voluntary (optional). My child can refuse to participate, or stop at any time without penalty. I can have my child’s comments or any records returned to me or request they be destroyed.______
Print Name of Parent/GuardianSignature of ParticipantDate
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Signature of Interviewer/ResearcherDateSignature of Parent/GuardianDate